Supparative thrombophlebitis of facial vein: a variant of lemierre’s syndrome

Introduction: Lemierre’s syndrome refers to infectious thrombophlebitis of the jugular vein most commonly caused by Fusobacterium Necrophorum. The thrombophlebitis is a serious condition that may lead to systemic complications if not treated promptly. Case Description: This case involved a 33-year-old Hispanic female who presented with a 6-day history of fever, chills, nausea, vomiting and profound diarrhea. She received aggressive hydration and required pressors for persistent hypotension. Patient was started on broad spectrum antibiotics for sepsis of unknown origin. Her gastrointestinal symptoms resolved with above treatment; however, she continued to have fever and significant leukocytosis. Meanwhile, she complained of swelling of her right neck. Patient reported a history of dental abscess on the right side 3 months ago, but denied any current symptoms. Her initial blood cultures obtained in the ED grew Fusobacterium necrophorum. Although she did not have the typical history of pharyngitis, given the suspected submandibular lymph node and blood cultures growing Fusobacterium species, Lemierre’s syndrome was suspected and neck/chest/abdomen/pelvis CTs were obtained to investigate the source of infection and possible systemic septic emboli. The CTs indicated purulent thrombophlebitis of the right facial vein and periapical abscess of the right maxillary incisor, where a branch of the right facial vein was draining from. In addition, there were cavitary lesions in the right upper lobe of lung, which were suspicious for septic emboli. It is considered, that she had a variant of Lemierre’s syndrome. She was on intravenous metronidazole until her fever resolved and leukocytosis trended down. She continued oral Augmentin and amoxicillin for three weeks. Discussion: This case illustrates a variant of Lemierre’s syndrome that does not have preceding pharyngitis, involves the facial vein, and presents with prominent gastrointestinal symptoms. Recognizing atypical presentations of Lemierre’s syndrome is essential as prompt treatment is the key to prevent serious systemic complications